Provider Demographics
NPI:1003930967
Name:MUSGRAVE, GARY D (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:MUSGRAVE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 N. COLE RD.
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-377-9930
Mailing Address - Fax:208-377-9932
Practice Address - Street 1:3314 N. COLE RD.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-377-9930
Practice Address - Fax:208-377-9932
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1306111NS0005X
OH1586111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341690892-00OtherBWC
OH000000136764OtherANTHEM
OH341690892-00OtherBWC
OHMU0704991Medicare ID - Type Unspecified